Get (form 1) - Referral_registration Form Hrif - Ccshrif.org - Ccshrif

Filling out the Referral_Registration Form HRIF is a crucial step in accessing quality care for high-risk infants. This guide is designed to provide clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the referral date in the specified format of MM/DD/YYYY. This date is important for tracking purposes.
3. Provide the HRIF I.D. number, if available, which aids in identifying the infant's records.
4. Fill in the hospital or center information, noting that this section is optional and for internal use only.
5. Input the infant's first name and last name, including any alternate names they may have (up to two).
6. List the primary caregiver's first and last name, followed by their street address, city, state/country, home phone number, and zip code.
7. If applicable, provide an alternate street address and alternate phone number for the caregiver.
8. Complete the program registration information by entering the CCS number, CPQCC reference number, date of birth (MM/DD/YYYY), birth hospital, birth weight in grams, and specify if the infant is a singleton or part of a multiple birth.
9. Select the infant's gender and fill in the gestational age, indicating weeks and days.
10. Choose the infant's ethnicity and race, ensuring to follow the provided categories.
11. Enter the date of discharge to home and the referring CCS NICU.
12. Record the biological mother's date of birth and their ethnicity and race using the same categories as above.
13. Indicate the insurance type by checking all that apply.
14. Select the primary caregiver’s relationship, specifying the caregiver’s primary language and their education level.
15. Complete the medical eligibility profile by checking any conditions that apply to the infant.
16. Once you have completed all required fields, review your entries for accuracy.
17. Save your changes, and choose to download, print, or share the completed form as needed.

Take the first step towards quality care—complete the Referral_Registration Form HRIF online now.